Understanding and Managing Anxiety in Students with Autism Spectrum Disorder (Part II)

Symptoms

You may have gotten a glimpse of signs of anxiety from the definitions stated at the beginning, such as feelings of tension, fear, panic, worried thoughts, crying, whining, fast heart rate, sweating, shaking, etc. Furthermore, as discussed earlier, some symptoms of anxiety overlap with symptoms of ASD. While it is not always easy to recognize anxiety in a child with ASD, parents/caregivers normally know what behaviors to expect from the child. It takes time and patience to get to know an individual with ASD well enough to separate autistic behaviors and signs of anxiety. Parents and siblings are often better than anyone else at noticing anxiety in a child with autism due to the amount of time being around him/her. Other than those already stated, caregivers and teachers need to be on the lookout for signs of anxiety below7, 14:

• Changes in appetite: Lose one’s appetite or eat more than usual

• Sleep disturbance: May struggle to fall asleep or stay asleep

• An increase in repetitive or compulsive behaviors

• An increase in sensory sensation-seeking behaviors

• Appear frightened or apprehensive

• Be unwilling to leave the house

• Have more emotional meltdowns than usual or be unusually upset

• Begin to behave in aggressive or self-abusive ways

• Refuse to go into certain places or rooms

• Place hands over eyes or ears

• Appear unusually jumpy (paces, flicks, rocks, or mumbles more than usual)

Data collection: Keep a journal to track the child’s behaviors and moods. Notice changes in sleep, appetite, excitement over special interests, and overall daily behaviors moods.

Anxious Brain

Students with ASD will not be interested in learning coping skills if they don’t understand why the coping skills they are about to learn are relevant to them and can help manage their anxiety. One of the first things they need to learn is how their body reacts to stress and anxiety. By talking about how the nervous system responds to stress and anxiety and how coping skills can counteract those reactions, children with ASD will likely gain a good understanding of learning and using coping skills to manage their anxiety. Like teaching anything else, teachers need to adjust the terms and concepts in their explanations to match the child’s age and abilities.

When a person senses a threat (i.e., a stressor), the information from the ears and eyes goes to the amygdala, a part of limbic system and is an almond-shaped structure deep in the brain. The amygdala interprets the images and sounds and sends distress signal to the hypothalamus when it perceives danger.15, 16 This area of the brain communicates with the rest of the body through the autonomic nervous system (ANS), which consists of two parts, the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The sympathetic nervous system triggers the “fight or flight” response and functions like a gas pedal in a car. It responds to the perceived threat and prepares you for action, whether to fight off a threat or flight to safety. On the other hand, the parasympathetic nervous system acts like a brake promoting the “rest and digest” response that calms the body down after the danger/threat has passed.

After the amygdala sends a distress signal, the HPA axis (hypothalamus-pituitary gland-adrenal glands axis) activates the sympathetic nervous system by sending signals through the autonomic nerves to the adrenal glands, small structures sitting atop the kidneys. These glands respond by releasing the hormone epinephrine (a.k.a. adrenaline) into the bloodstream. As epinephrine circulates through the body, it brings on a number of physiological changes, e.g., faster heart beats, higher pulse rates and blood pressure, breathing more rapidly, small airways in the lungs open wide so the lungs can take in more oxygen, extra oxygen sent to the brain for increasing alertness, vision, hearing and other senses become sharper, etc. All of these changes happen so quickly that people aren’t aware of them. As the initial surge of epinephrine subsides, the HPA axis causes the adrenal glands to release another stress hormone, cortisol. Like adrenaline, cortisol causes changes in our body to cope with the threat and keep ourselves safe. When the threat passes, cortisol levels fall and the parasympathetic nervous system, the brake, activates the “rest and digest” response to help the body get back to normal, e.g., bringing the heart rate back down, slowing the breathing pace, reducing tension in the muscles.15, 16

While the reactions of our ANS work automatically in response to the presence or absence of a threat or stressor, we can learn to regulate some of the reactions by acting in a way that taps into the PNS (such as breathing and relaxing muscle tension), so we will be more relaxed in both body and mind.12

Instead of covering every detail of the anxious brain described earlier, teachers should select the parts that are suitable to students based on their functioning levels. The aim is to set the stage for relaxation training by explaining how our body reacts to anxiety. For younger children, seemingly foreign terminologies such as sympathetic and parasympathetic nervous system could be replaced by easier or fun terms such as hot mode/cold mode; or stressful Sam/peaceful Pat.13

Strategies

Other than those stated earlier for each of the “prime suspects” for anxiety in students with ASD, in this section general principles/guidelines and strategies are presented in helping them manage their anxiety.3, 7, 9, 12, 13, 14, 17

1. Removing the stressor or removing the student from the anxiety-causing situation, or addressing the situation, e.g., removing bright lights or loud noises, removing the child from crowded areas, addressing the bullying issue.

2. Making accommodations or providing supports, e.g., reducing sensory input by wearing sound-canceling headphones or sunglasses, creating clear schedules or routines by using visual support and social stories, Best Buddies or other peer-to-peer programs to reduce social anxiety. Other common accommodations that are commonly used for students with disabilities can help with anxiety issues as well, e.g., preferential seating, pre-arranged

   breaks, exit plan/a safe place in the classroom or school, extended time for tests/exams, identifying any changes to routine well in advance, etc.

3. Addressing contributing skill deficits, e.g., coach the child on how to initiate a conversation.

4. Teaching coping skills: Despite the best environmental accommodations and supports described above to help prevent or minimize anxiety, children need to learn coping skills for the following reasons12:

   1. All sources of anxiety can never be eliminated.

   2. There won’t always be a supportive person nearby to help the student.

   3. Coping skills help the student develop confidence and problem-solving skills ultimately leading to independence.

      Prior to children learning coping skills, they need to make known why and how the skills are important, relevant and helpful to their everyday life, so they will be motivated to learn and to apply as much as possible. The students need to be aware of the impact of anxiety on their lives (e.g., anxiety makes it difficult to concentrate, sleep well, play or work with other students). Another way to motivate students to learn coping strategies is to provide them with rationales behind the skills. For example, belly breathing helps alleviate anxiety by increasing oxygen flow to the lungs and activates the vagus nerve (the largest cranial nerve) and in turn activates the PNS sending the signal to the brain to relax.18

      Behavioral Coping Strategies: These are activities children can do to relax their bodies and calm their minds when they are anxious.

      1. Relaxation skills13

         1. Deep breathing

         2. Progressive muscle relaxation: There are many variations on this technique. Depending on the student’s preference and needs, some may do both “loose and tense” when working on each body area; others may focus on “loose” only.

         3. Body scan

         4. Imagery (peaceful images)

         5. Meditation: There are many variations. It basically is a kind of focused awareness that helps break the pattern of anxious thoughts.

      2. Exercise23: Research shows exercise 30 minutes will temporarily reduce anxiety. Reese (2020) stated that anxiety triggers adrenalin to release. Once it’s released, it will not go away and needs physical activity to burn if off. Thus, physical activity is one of the best ways in dealing with anxiety and trauma.

      3. Stretching/yoga for children

      4. Talk to a trusted person

      5. Engage in special interests

      Cognitive Coping Strategies:

      1. Identify anxiety triggering thoughts (e.g., the dog across the street barking is going to bite me).

      2. Identify adaptive thoughts by using “fighting back with facts” (e.g., the dog is on a leash, so I should be safe).

5. Psychological intervention

   Cognitive behavioral therapy (CBT) is widely considered to be the most effective evidence-based treatment for both neurotypical children ad adults with anxiety disorders as well as youth with high-functioning ASD.2, 19, 20 It involves seven steps2, 3:

   1. Psychoeducation: Explaining the nature of anxiety and the rationale for treatment.

   2. Somatic management: Teaching the individual to identify his/her bodily cues for anxiety, increasing awareness of somatic sensations associated with anxiety.

   3. Cognitive restructuring: Identifying anxious thoughts or “self-talk,” teaching the individual to challenge or dispute the accuracy, likelihood, or usefulness of those anxious thoughts. Replace anxious self-talk with more accurate, probable, or productive thoughts.

   4. Teaching coping skills such as relaxation (belly breathing, progressive muscle relaxation and/or coping self-talk).

   5. Developing a hierarchy of feared stimuli/situations.

   6. Developing a positive reinforcement system for rewarding brave behavior (i.e., exposure to those feared situations).

   7. Gradual/hierarchical exposure to feared situations: Students work through steps of hierarchy using coping strategies to manage anxiety. Guiding students without pushing them. They dictate pace.

      Modified CBT with the same key elements was used for individuals with ASD. Modifications included increased structure and emphasis on visuals, presenting concepts more concretely, more practice opportunities to use concepts and skills, and increased parental involvement.2

6. Strategies to deescalate meltdowns:

   Wehrenberg (2018) stated that meltdowns are not tantrums but outcome of stress built to the student’s breaking point. You might see students exhibit the following behaviors22:

   • Agitation revealed in stimming

   • Trouble processing questions, repeating statements

   • Conversation gets louder and louder

   Dr. Baker (2021) likens “Dr. Banner vs. the Hulk” to students with ASD who are able to use their forebrain/reflective brain for reasoning and planning (Dr. Banner) vs. those who are not thinking logically when threatened. Their limbic system hijacks the rest of the brain (the Hulk). They have no time for logic, but exhibit outward rage or inward depression.21

   Crisis Management of the Hulk21: Don’t threaten further at that moment.

   1. Non-verbal and ensure the student’s safety, e.g., walk away and say something like, “When you need me, I’ll be at my desk.”

   2. When the child’s logic is gone (his/her forebrain is not thinking), no top-down approach such as cognitive behavioral theory (CBT), but distract him/her by using the following items or activities.

      1. Novel items, e.g., “Did I show you the gold coin?”

      2. Special interest: Allow the child to play with his/her favorite items/toys.

      3. Sensory activities: A snack, music, etc.

         Items a) – c) are not to reward the child’s tantrum, but to “distract.” In the end, the adults (teachers or parents) need to make a plan for next time.

      4. When the child is able to calm down and talk, ask him/her, “What do you want? Let’s find a better way to get it.”

      5. Make a plan for next time.

7. Medication management: This is frequently prescribed in older youth and adults with anxiety disorders. Unfortunately, there is limited data on the use of anxiety medication for individuals with ASD.3, 14 In some cases, medication provided under close medical supervision can help control anxiety while the individual builds skills.

References

1. American Psychological Association (n.d.). Anxiety. Retrieved from https://www.apa.org/topics/anxiety

2. Moskowitz, L. J. & Jeffay, M. (2021) Assessing and treating anxiety in individuals with autism spectrum disorder. In S. M. Edelson, and J. B. Johnson (Eds.), Understanding and Treating Anxiety in Autism. London and Philadelphia: Jessica Kingsley Publishers. 199- 240.

3. Keefer, A. (2019). Anxiety in children with autism spectrum disorder. Presented at Autism Research Institute webinar on March 6, 2019. Retrieved from https://www.youtube.com/watch?v=wkM6z-4WWQs

4. van Steensel, F. J. A., Bogels, S. M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review, 14, 302-317.

5. White, S. W., Oswald, D., Ollendick, T., and Scahill, L. (2009). Anxiety in children and adolescents with autism spectrum disorders. Clinical Psychology Review, 29, 216-229.

6. Moskowitz, L. J. & Edelson, S. M. (2021). Introduction. In S. M. Edelson, and J. B. Johnson (Eds.), Understanding and Treating Anxiety in Autism. London and Philadelphia: Jessica Kingsley Publishers. 14-22.

7. Rudy, L. J. (2022). Helping people with autism manage anxiety. Retrieved from https://www.verywellhealth.com/anxiety-and-autism-4428086?print

8. Joyce, C., Honey, E., Leekam, S. R., Barrett, S. L., and Rodgers, J. (2017). Anxiety, intolerance of uncertainty and restricted and repetitive behavior: Insights directly from young people with ASD. Journal of Autism and Developmental Disorders, 47, 3789- 3802.

9. Rodgers, J. (2018). Anxiety in autistic people. Retrieved from https://www.autism.org.uk/advice-and-guidance/professional-practice/anxiety-autism

10. Alfano, C. A., Beidel, D. C., & Turner, S. M. (2006). Cognitive correlates of social phobia among children and adolescents. Journal of Abnormal Child Psychology, 34(2), 182-194.

11. Merrill, A. (n.d.). Anxiety and autism spectrum disorders. Retrieved from https://www.printfriendly.com/p/g/XwDsjV

12. Lynch, C. (2019). Anxiety management for kids on the autism spectrum: Your guide to preventing meltdowns and unlocking potential. Arlington, TX: Future Horizons Inc.

13. Lynch, C. (2020). Anxiety, autism, and the five prime suspects. Presented at Autism Research Institute webinar on March 25, 2020. Retrieved from https://www.google.com/search?client=firefox-b-1- d&q=Christopher+Lynch%3A+Anxiety%2C+Autism%3A+Five+Prime+Suspects#fpstat e=ive&vld=cid:b5d24ec6,vid:fkA5zhRp4pM

14. Autism Research Institute (n.d.). Autism and anxiety. Retrieved from https://www.autism.org/autism-and-anxiety/

15. Harvard Health Publishing-Harvard Medical School (2020). Understanding the stress response. Retrieve from https://www.health.harvard.edu/staying-healthy/understanding- the-stress-response?gclid=CjwKCAiA9NGfBhBvEiwAq5vSy07- F2xlEIVBOiMD4aVhAOTTuJ01Rktg-teWMqE71nVCX_Db1zgegRoCkV4QAvD_BwE

16. Garafola, M. (2020). The science of stress: Understanding your stress response. Retrieved from https://ctsciencecenter.org/blog/the-science-of-stress-understanding-your- stress-response/

17. Middletown Centre for Autism (2021). Autism and managing anxiety: Practical strategies for working with children and young people. New York, NY: Routledge.

18. Sweeton, J. (2019). Trauma treatment toolbox. Eau Claire, WI: PESI Publishing & Media.

19. van Steensel, F. J. A., & Bogels, S. M. (2015). CBT for anxiety disorders in children with and without autism spectrum disorders. Journal of Consulting and Clinical Psychology. 83, 512-523.

20. Ung, D., Selles, R., Small, B. J., and Storch, E. A. (1015). A systematic review and meta- analysis of cognitive behavioral therapy for anxiety in youth with high-functioning autism spectrum disorders. Child Psychiatry and Human Development, 46, 533-547.

21. Baker, J. (2021). No more autism meltdowns: Strategies to deescalate meltdowns and reduce anxiety. Presented at the 2021 Certified Autism Spectrum Disorder Clinical Specialist Intensive Training, Eau Claire, WI: PESI, Inc.

22. Wehrenberg, M. (2018). Working with autism and anxiety: Hidden problems and effective solutions. Eau Claire, WI: PESI, Inc.

23. Reese, C. (2020). Trauma-informed compassionate classrooms: Strategies to reduce challenging behavior, improve learning outcomes and increase student engagement. PESI seminar.